History and Physical Examination 7
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Medical Documentation
History and Physical Examination
Identifying Data: Patient's name; age, race, sex. List the patient's significant
medical problems. Name of informant (patient, relative).
Chief Compliant: Reason given by patient for seeking medical care and the
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when it began, character of the symptoms, location where the
symptoms began; aggravating or alleviating factors; pertinent positives and
negatives. Describe past illnesses or surgeries, and past diagnostic testing.
Past Medical History (PMH): Past diseases, surgeries, hospitalizations;
medical problems; history of diabetes, hypertension, peptic ulcer disease,
asthma, myocardial infarction, cancer. In children include birth history,
prenatal history, immunizations, and type of feedings.
Medications:
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder.
Asthma, coronary artery disease, heart failure, cancer, tuberculosis.
Social History: Alcohol, smoking, drug usage. Marital status, employment
situation. Level of education.
Review of Systems (ROS):
General: Weight gain or loss, loss of appetite, fever, chills, fatigue, night
sweats.
Skin: Rashes, skin discolorations.
Head: Headaches, dizziness, masses, seizures.
Eyes: Visual changes, eye pain.
Ears: Tinnitus, vertigo, hearing loss.
Nose: Nose bleeds, discharge, sinus diseases.
Mouth and Throat: Dental disease, hoarseness, throat pain.
Respiratory: Cough, shortness of breath, sputum (color).
Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dyspnea;
dyspnea on exertion, claudication, edema, valvular disease.
Gastrointestinal: Dysphagia, abdominal pain, nausea, vomiting,
hematemesis, diarrhea, constipation, melena (black tarry stools),
hematochezia (bright red blood per rectum).
Genitourinary: Dysuria, frequency, hesitancy, hematuria, discharge.
Gynecological: Gravida/para, abortions, last menstrual period (frequency,
duration), age of menarche, menopause; dysmenorrhea, contraception,
